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N, F <br /> SAN JOAQUIN COUNTY PUBLIC HEATH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> P here made to San Joaquin County for a permit to construct and/or install the work herein described. This } <br /> Application is hereby i <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> de l `A G�7�� City Lot Size/Acreage <br /> Job Address .-... `•'VY� <br /> I <br /> s <br /> Address ne <br /> Owner's Name I <br /> (A <br /> Address t !? icense No Phone 1 <br /> Contractor ' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service Well I <br /> SYSTEM REPAIR OTHER O Monitoring Well <br /> PUMP INSTALLATION ❑ ' ­ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION • AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> C] Industrial ❑ Open Bottom ft]] Manteca Dia. of Well Excavation- 9 <br /> omesticlPrivate ❑ Gravel Pack C7 Tracy Type of Casing_ Specifications <br /> I'I Public 1-1 Other fl.Delta Depth-of-Grout Seal -- Type of Grout <br /> i I irrigation _ Approx. De Ih �i Eastern Surface Seal Installed by <br /> Repair Work Done k Type of Pump H.P. State Work Dane <br /> Well Destruction ❑ Welf Diameter Sealing Material & Depth , <br /> Depth r> r., Filler Material & Depth, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION,t.I REPAIR/ADDITION 11' DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 2W feet.) <br /> installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> I SEPTIC TANK. r '❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ - ----- Method of Disposal <br /> t <br /> Distance to nearest:J •Well-- - Foundation _ Property Line <br /> LEACHING LINE C1 No. & Length of lines ' t Total length/size <br /> N FILTER BED [3 Distance to nearest: Well Foundation Properly Line <br /> r- <br /> kSEEPAGE PITS 'l I Depth Size Number <br /> kSUMPS El Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of th6 work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of C nia.I <br /> The app' nt must all for all required in tons. Complete drawing on reverse <br /> Signed Title: Date: + <br /> OR DEPARTMENT USE ONLY q <br /> Application Accepted by <br /> Date L Ares <br /> Pit or Grout inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N'San Joaquin, Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED A RECEI ED BY DA E PERMIT'NO. <br /> INFO _ <br /> . Err 13-24 IREV, <br /> EH 11.26 ` .` ,•✓ <br /> / f <br />